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‘Like a miracle:’ Douglas woman’s stroke is case study for a fast, efficient system of care

By kbleizeffer Jan 4, 2016

Neurointerventional radiologist Dr. Charles Bowkley, M.D., at left, poses with Rebecca Renstrom in front of images of the blood clot that could have killed her. A few days later, she walked out of the hospital, with no residual deficits.

By all measures, Sept. 29 began as a typical day. Rebecca L. Renstrom walked her dog, went to work and came home for lunch. She felt fine when she returned to the Douglas Chamber of Commerce, where she works one day a week, early that afternoon.

She finished folding some Chamber brochures and put them in the closet. When she sat back down, her boss noticed that Renstrom’s face was drooping. She was drooling and not making any sense. Her boss picked up the phone and dialed 911.

“I’m OK! I’m OK,” Renstrom protested.

“No you’re not,” her boss answered. “You’re having a stroke.”

Life-saving stroke care is measured in minutes. Time is brain, the saying goes, and the faster doctors open the blocked blood vessel, the better the chance of survival and recovery. From the moment Renstrom’s boss dialed 911 to the moment Charles Bowkley, M.D., a neurointerventional radiologist, pulled the clot from her brain, Renstrom’s case is a study in stroke care at Wyoming Medical Center. Every step of the stroke protocol happened as it should.

“I think the most amazing thing about this case is how well our system of care worked,” said David Wheeler, M.D., a neurologist at Wyoming Neurologic Associates and medical director of WMC’s Primary Stroke Center. “Mrs. Renstrom’s case represents the culmination of a decade of work putting a system of care in place. I’m really confident that this can happen for every patient now.”

Case study, minute by minute

At the 2015 International Stroke Conference, Wyoming Medical Center was one of 35 hospitals, out of about 1,000 stroke centers across the country, to earn the American Stroke Association’s highest honor for fast, effective stroke care. Our multidisciplinary stroke team is made up of members from nearly every department in the hospital including EMS, ER nurses and physicians, radiology, laboratory, pharmacy, ICU, neurology, therapies, case managers and more. The team meets monthly to analyze the latest data, collaborate on best care practices and troubleshoot areas that need improvement.

David B. Wheeler, M.D., director of Wyoming Medical Center's Primary Stroke Center, says 'Renstrom's case represents the culmination of a decade of work putting a system of care in place.'

“Renstrom’s case shows how all the pieces work together,” Dr. Wheeler said. Here’s how it happened, step by step.

3:15 p.m.: Renstrom’s boss calls 911. Calling 911 at first sign of symptoms is the single most important step in getting stroke treatment in time. And it is completely up to you – the general public. Clot buster is only effective if administered within 3 ½ to 4 ½ hours after onset of symptoms, and stent removal of clots is only effective within about 6 hours. Delay too long, and brain tissue dies – greatly increasing risk of death or permanent disability. Calling 911 activates our stroke team, and there’s no chance you or a loved one will be delayed in the waiting room.

“That is one thing that is changing for the better: With all our efforts to increase community awareness, more patients are coming to the Emergency Room within the treatment window. Mrs. Renstrom’s boss calling 911 was the right thing to do. A few years ago, that might not have happened,” Wheeler said.

3:38 p.m.: Renstrom arrives at Converse County Memorial Hospital via ambulance. By the time Renstrom arrived in the Douglas ER, the emergency physician noticed a marked improvement in her stroke symptoms. The physician called the WMC referral center which connected him with Dr. Wheeler. ”Is it still appropriate to administer the clot buster tPA to a patient who appears to be improving?” the doctor asked.

“It is,” Wheeler answered. Just a couple of years ago, tPA was not administered if a patient appeared to be getting better to avoid potentially harmful side effects. But evidence shows that even stroke patients who appear to improve at first end up deteriorating later. Patients who get tPA early show better outcomes.

While still on the phone, the Douglas doctor sent Renstrom’s CT scan to Dr. Wheeler. tPA was started at 4:29 p.m. in the Douglas ER and finished on the ambulance ride to WMC. Dr. Wheeler activated Wyoming Medical Center’s stroke team and awaited her arrival.

5:39 p.m., Renstrom arrives at WMC. Renstrom bypassed our ER and was taken straight to radiology for the stroke protocol CT – imaging that takes many pictures of the blood vessels in the brain so that doctors can pinpoint the precise location of the clot. Renstrom’s condition had appeared to improve dramatically. Dr. Wheeler and Dr. Bowkley, Wyoming’s only neurointerventional radiologist, thought further treatment might not be necessary.

But the stroke CT showed tPA had not busted the clot. The doctors saw a blockage in the right middle cerebral artery, just behind her eyeball and about as long as ¾ of her eyebrow.

“It was a pretty big clot,” Dr. Bowkley said. “She basically had no blood flow to the outside of her brain.”

Immediately after the scan, Renstrom’s symptoms returned: “She was completely paralyzed on the left side, her eyes were forced to the right and she could barely speak,” Wheeler said.

Intra-arterial clot retrieval

In January 2015, the first of three major studies on the effectiveness of new-generation clot retrieval devices was published in the New England Journal of Medicine. The studies – MR. CLEAN, ESCAPE and EXTEND-IA – showed that stent-removal of clots from the brain, along with clot buster management, dramatically improved outcomes for certain stroke patients. The results were so convincing that a couple of the trials were stopped early, Wheeler said. The standard of care completely shifted.

“It was a quick switch and a dramatic improvement in quality of outcomes.,” Wheeler said. “Combining fast treatment with tPA – and clot retrieval when tPA doesn’t work – the probability that a stroke patient leaves our hospital without symptoms is a lot higher.”

Renstrom is a perfect example.

At 6:08 p.m., Dr. Bowkley began clot retrieval with the Solitaire Stent Retriever. He accessed the common femoral artery near Renstrom’s groin and inserted a small guide wire covered with a vascular sheath – or a small tube. With real-time X-ray imaging, Bowkley snaked the guide wire through Renstrom’s arteries, up to and around her heart, into the internal carotid artery behind her jawbone and through the middle of the clot in her cerebral artery.

Images of Rebecca Renstrom’s brain show blood flow resume after insertion of the Solitaire Stent Retriever into her blood clot, seen as the lima-bean shaped bulge in the cerebral artery. At left, the retriever (seen as a hair-thin white line) is threaded through the clot. Doctors leave it there for a few minutes to allow blood flow to resume before pulling it out and bringing the clot with it. At right, blood flow is restored to the outer regions of the brain.

The stent retriever isn’t a true stent but more like a small rolled-up chicken wire fence. After he passed it through the clot, he let blood flow through for five minutes, delivering oxygen to parts of the brain that had been deprived. Then, Bowkley slowly pulled the stent back through the catheter, taking Renstrom’s clot with it.

In less than hour, at 7:02 p.m., the clot causing Renstrom’s stroke was outside her body.

“She truly is a miracle of modern medicine,” Dr. Bowkley said. “In the appropriate patient, this type of therapy is the gold standard. Without it, even a few years ago, Mrs. Renstrom very likely would not have left the hospital, or she would have gone to rehabilitation with significant residual deficits and had a markedly different course of events following her stay at Wyoming Medical Center.”

As it turned out, Renstrom left the hospital in two and a half days and required no follow-up rehabilitation.

Wyoming Medical Center is the only hospital in Wyoming with 24/7 coverage of interventional radiologists – the specialists that make clot retrieval possible.

‘Like a miracle’

By the time Renstrom walked out of the hospital, not even her family members could tell she had a stroke. Doctors asked her to follow up with a physical therapist in Douglas, but after evaluation, the therapist told her she didn’t need their services.

Dr. Charles Bowkley shows Rebecca Renstrom images of her brain taken during her stroke. A few days later, even her family couldn't tell she'd had one. 'I thought a stroke meant you are debilitated for the rest of your life – or at least it’s going to be a long road back. For me, to be able to do everything I’ve always done, it’s like a miracle,' she said.

Renstrom uses the same word as Dr. Bowkley to describe her case: “I thought a stroke meant you are debilitated for the rest of your life – or at least it’s going to be a long road back. For me, to be able to do everything I’ve always done, it’s like a miracle,” she said. “What the medical field can do now is absolutely remarkable.”

From her nurses in ICU and on the neuro floor, to the quick seamless care from one step to the next, Renstrom admits she didn’t know care like hers was available here. Until you need it, you don’t think about it, she supposes.

“In little old podo (podunk) Wyoming, you don’t expect care like this. I was extremely impressed with the doctors. As far as I’m concerned, they rock and I have full confidence in them,” she said. “When you go to the Casper hospital, they take good care of you.”

David Wheeler, MD, PhDDr. David B. Wheeler is board certified in neurology and clinical neurophysiology. He is a Rhodes Scholar and was the 2010 Wyoming Medical Center Physician of the Year. He serves on the boards for Wyoming Medical Center, Wyoming Dementia Care and the American Heart Association (Southwest Affiliate.) He practices at Wyoming Neurologic Associates, 1020 E. Second St., Suite 100 in Casper. For a referral or an appointment, call (855) 39-BRAIN.

Charles W. Bowkley III, MDDr. Bowkley is the only neurointerventional radiologist in Wyoming. He is board certified in diagnostic and vascular / interventional radiology. He joined the staff at Casper Medical Imaging and Outpatient Radiology in 2010 and also practices at Wyoming Medical Center. Call (307) 265-1620 for an appointment or referral.